AED - Superficial Corneal Diseases - Week 9 Flashcards by Davud Akgun

How thick is the cornea centrally? Give a range.

490-560 microns

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How many cells thick is the corneal epithelium? What does this prevent the diffusion of?

6-8 cells thick

Prevents diffusion of fluorescein

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What layer of the cornea is significant in recurrent corneal erosion?

Basement membrane

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Consider trauma to Bowman’s layer of the cornea. Does it regenerate?

No regeneration following trauma

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What happens to Descemet’s membrane during oedema?

Folds occur

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Do endothelial cell numbers remain constant as we age? Can they regenerate if they are lost?

Cell numbers decrease with age and do not regenerate

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How does drop toxicity appear with staining?

Small spots of fluorescein distributed evenly across the cornea

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What constitutes filamentary keratopathy (2) and what is it usually due to (2)?

Usually due to abnormal areas of corneal epithelium and excess mucus in tears
Requires corneal irregularity in conjunction with tear film abnormality

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In filamentary keratopathy, what adheres strongly to the corneal surface?

Filaments - mucous strands attached to abnormal epithelial cell plaques

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Is filamentary keratopathy common? List 5 common causes of this condition.

Uncommon
Severe dry eye
Superior limbic keratoconjunctivitis
Ocular surgery (cataract/corneal graft)
Recurrent corneal erosion
Neurotrophic keratopathy

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List 4 symptoms of filamentary keratopathy. Explain why they occur if applicable (3).

Foreign body sensation
-pulling on filaments with blink
watery eye
-due to stimulated reflex tears
Decreased VA
-due to filaments and poor tear flims
Photophobia

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What appearance do filaments in filamentary keratopathy have? What colour and how long? What do they stain well with? What about fluorescein? Which end of the filament is adherent and to what?

Greyish filaments, one to several mm in length
Stains well with rose bengal and lissamine green
Less well with fluorescein
Adherent to corneal plaque at the proximal end of the strand.

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List three components to assessing filamentary keratopathy.

Good history

Appropriate slit lamp and tear assessment

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How are filaments in filamentary keratopathy treated? Are they recurrent?
What does removal of the filament cause and can it be treated?

They are removed under local anaesthesia using sterile forceps
Will reccur if the underlying cause isnt treated
Removal will cause an epithelial defect - topical antibiotic prophylaxis

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Aside from treating the filament itself, list 4 treatment options for filamentary keratopathy.

Ocular lubricants
Topical corticosteroids if filaments are persistent
Bandage contact lens
Topical acetylcysteine

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How common is superficial punctate keratopathy? What acronym is used for it? What is it due to?

Very common
Also called PEE
Due to superficial damage (erosion) of the surface corneal epithelium

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List 8 common causes of superficial punctate keratopathy.

Dry eye
Drug toxicity
Foreign body
Contact lenses
Hyopxia
Lid disease
Corneal disease
Thygeson's superficial punctate keratopathy

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What three dyes does superficial punctate keratopathy stain with?

Fluorescein
Rose bengal
Lissamine green

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What does the position of staining/erosion in superficial punctate keratopathy indicate?

It may determine cause

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List symptoms of superficial punctate keratopathy (3).

May be asymptomatic

If symptomatic - gritty and photophobia

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What may happen if superficial punctate keratopathy is dense?

Visiond loss

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List 5 signs of superficial punctate keratopathy.

Fine, coarse, dense, or sparse areas of superficial corneal epithelial erosions
Eyes remain white and clear

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List 6 components for assessing superficial punctate keratopathy.

History
Slit lamp
Fluorescein
Wratten filter
Tear workup
Identify underlying cause

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Within what time period will superficial punctate keratopathy typically repair? What can promote repair?

Within 24h

Ocular lubricants can promote repair

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If wearing contact lens and superficial punctate keratopathy is noticed, what advice should be given?

Discontinue contact lens wear

Are corneal infiltrates present with superficial punctate keratopathy?

What may be required if superficial punctate keratopathy is severe (3)?

Prophylactic topical antibiotic cover Steroids -only if underlying condition is inflammatory

Are subepithelial infiltrates common or rare? What are they due to?

Relatively common due to inflammatory response within the anterior corneal stroma -leukocyte infiltration

List 5 common causes of subepithelial infiltrates.

``` Viral infection Blepharitis Tygeson's SPK Preservative toxicity Contact lenses ```

List 5 symptoms of subepithelial infiltrates.

``` Foreign body sensation Photophobia Watery eye Decreased visiond if central SPK over the area of infiltrate ```

How do subepithelial infiltrates appear? What may happen with the overlying epithelium?

Appears as a subepithelial, diffuse grey opacity | Overlying epithelium may stain with fluorescein

List 6 components for assessing subepithelial infiltrates.

``` History Slit lamp Fluorescein Wratten filter Tear workup Identify underlying cause ```

What is a treatment option if subepithelial infiltrates are symptomatic?

Ocular lubricants

What should be done when treating subepithelial infiltrates?

Manage the underlying cause

What should be considered if there is significant epithelial breakdown over the infiltrate with subepithelial infiltrates?

Antibiotics

Can steroids be given for subepithelial infiltrates?

Yes, with a slow taper

Define CLARE-CIE and what it is.

``` Contact lens (induced) acute red eye It is an acute inflammatory event ```

What can lead to CLARE? What does it lead to (2)?

Contact lens tight fit can lead to a stasis of the tear film, causing a buildup of bacterial population under the lens and limbal hypoxia

What is the hallmark sign of CLARE in a contact lens wearer?

Corneal subepithelial infiltrates

List 5 symptoms of CLARE.

``` Discomfort Bulbar conjunctival redness Irritation Mild photophobia Watery eye ```

Within what time period does CLARE typically resolve? What percentage reccurs and within what time period? Why does this occur (2)?

88% resolves by day 22 Recurrence rate is 30% Most recurrence within 2 months Possibly due to not treating inflammation effectively and returning to contact lens wear too early

Why are antibiotics administered concurrently with anti-inflammatories for CLARE management (4)?

Decrease bacterial load More than normal discharge Unsure of diagnosis Optometrist peace of mind

Is CLARE inflammatory or infective, or both?

Inflammatory

How is inflammation in CLARE treated?

Steroids, which must be tapered

Is it ok to use ocular lubricants concurrently with steroids in CLARE?

Yes

What can be done to reduce recurrence of CLARE (3)?

No overnight wear Change to high Dk Change to dailies

Is neurotrophic keratopathy common or uncommon?

Uncommon

In what kind of eyes does neurotrophic keratopathy occur?

Diminished corneal sensation

What occurs with neurotrophic keratopathy in terms of metabolism and healing? List two additional consequences.

Decreased epithelial metabolism and healing Reduced reflex aqueous tear production Reduced epithelial trophic factors from nerves

List 6 common causes of neurotrophic keratopathy.

Previous herpes zoster or simplex keratitis Surgery/tumours Systemic diseases (diabetes) Topical drug therapy

List 4 symptoms of neurotrophic keratopathy.

Photophobia Conjunctival redness Decreased vision Pain unlikely

List three signs of neurotrophic keratopathy.

Range from SPK to large ulcers Reduced corneal sensation Surface or mild intra-ocular inflammation

Consider the ulcers with neurotrophic keratopathy. Do they usually have smooth/rough distinct/indistinct borders? What is their longest axis?

Smooth distinct borders | Longest axis is horizontal

List 8 components to assessing neurotrophic keratopathy.

``` History Slit lamp Fluorescein Wratten filter Lissamine green Tear workup Corneal senstivity Identify underlying cause ```

What is the mainstay of treating neurotrophic keratopathy?

Non-preserved ocular lubricants

Aside from the mainstay treatment, list 5 additional treatment options for neurotrophic keratopathy.

Withdrawal of topical medications if any (if theyre causative) Antibiotic ointment (chloramphenicol ointment) Non-preserved topical steroids Bandage contact lenses (increases infection risk) Referral for tarsorraphy

Is bullous keratopathy common or uncommon?

Not uncommon

What does bullous keratopathy occur due to?

Endothelial decomposition causing stromal/epithelial corneal oedema

List 5 common causes of bullous keratopathy.

``` Post-operative endothelial damage Endothelial dystrophy Trauma Angle closure glaucoma Contact lenses ```

List 4 symptoms of bullous keratopathy.

Pain Photophobia Decreased VA Haloes around lights

In what two regions does oedema occur with bullous keratopathy? for each, list two features.

Stromal corneal oedema -corneal opacification and folds in descemets membrane Epithelial corneal oedema -microcystic changes, a roughened corneal surface -bullae, distinct raised areas with negative staining

List 6 components to assessing bullous keratopathy.

``` History Slit lamp Fluorescein Wratten filter Specular microscopy Identify underlying cause ```

List 4 treatment options for bullous keratopathy.

Non-preserved ocular lubricants Hypertonic saline (5%) ads mainly the epithelium Bandage contact lens Refer for surgery

Is interstitial keratitis common or rare?

Very rare

What is interstitial keratitis?

Inflammation of the corneal stroma without primary involvement of the corneal epithelium or endothelium

List 5 symptoms of interstitial keratitis.

``` Congenital syphilis Tuberculosis HSV HZV Cogans syndrome ```

List 5 symptoms of interstitial keratitis.

``` Pain Photophobia Ocular ache Increased tearing Reduced vision ```

Is interstitial keratitis usually uni- or bilateral? Explain.

Bilateral if due to systemic disease | Unilateral with HSV/HZV infection

List 4 active signs of interstitial keratitis.

Stromal inflammation with oedema Corneal opacities Vascularisation AC reaction

List 3 inactive signs of interstitial keratitis.

Corneal opacification Corneal thinning Ghost vessels

What is the treatment option for interstitial keratitis? What cause requires urgent referral and why?

Treat corneal inflammation with potent, frequent topical corticosteroid Refer for treatment associated with systemic diseases Urgent referral is required if Cogan's is suspected as it can be life-threatening

List three symptoms of Cogan's syndrome.

Tinnitus Vertigo Deafness

Is marginal keratitis common or rare? Is it uni- or bilateral?

Common unilateral

What is marginal keratitis and what four things is it associated with?

``` A unilateral peripheral corneal lesion associated with: Staph. endotoxin hypelsensitivity Blepharitis Acne rosacea Contact lens wear ```

List 5 symptoms of marginal keratitis.

``` Redness Discomfort Photophobia Watery discharge Blurred vision ```

How does the lesion of marginal keratitis appear in size, colour, and numbers?

Sub-epithelial grey/white opacities ~1mm in size, often multiple

What can sometimes overlie the lesions in marginal keratitis?

Small epithelial defect

What are inferior lesions in marginal keratitis associated with?

Blepharitis

List two signs of marginal keratitis.

Adjacent conjunctival redness | Rarely anterior chamber reaction

List a differential diagnosis for merginal keratitis.

Microbial keratitis

List the 5 components to assessing marginal keratitis.

``` History Slit lamp Fluorescein Anterior chamber Lids ```

List three treatment options for marginal keratitis.

Topical steroids for inflammation Topical antibiotics for epithelial defect prophylaxis Treatment of underlying lid disease

What kind of keratitis is marginal keratitis?

Peripheral keratitis

Is phlyctenulosis common or rare? Is it uni- or bilateral?

Uncommon unilateral

What does phlyctenulosis look like?

Raised conjunctival/corneal lesion (phlycten)

In what population is phlyctenulosis typically found?

Young children

List a possible cause of phlyctenulosis.

Hypersensitivity to bacterial endotoxin

What is phlyctenulosis mainly found with (2)? Is it common in children (this particular cause)?

Mainly found with staph. blepharitis (uncommon in kids) and tuberculosis (disease itself is uncommon)

List 5 symptoms of phlyctenulosis.

``` Redness Discomfort Photophobia Watery discharge Blepharospasm possible ```

List 6 signs of phlyctenulosis.

May be conjunctival, limbal, or corneal A raised pink/white nodule Ocassional overlying epithelial defect Associated corneal/conjunctival vascularisation over weeks

List 4 differential diagnoses for phlyctenulosis.

Microbial keratitis Marginal keratitis Pingueculum Granuloma

List the four components to assessing phlyctenulosis.

History (TB) Slit lamp Fluorescein Lids (blepharitis)

What is recommended if there is concern for a tuberculosis caused case of phlyctenulosis?

Refer for a chest x-ray, mantoux and sputum culture

What is the treatment/management for phlyctenulosis?

Manage staph. lid disease if appropriate | Monitor for improvement

What kind of keratitis is phlyctenulosis?

Peripheral keratitis

Is moorens ulcer common or rare?

Rare

Describe moorens ulcer, including what its related to, its progression, and in which populations (gender included if applicable) in which it is more or less aggressive and if its uni- or bilateral.

An idiopathic, slowly progressive, ulcerative lesion of the peripheral cornea - less agressive and unilateral in elderly - more aggressive and bilateral in young males

List 4 symptoms of moorens ulcer.

Conjunctival redness Pain Photophobia Mucus/watery discharge

List 2 signs of moorens ulcer.

Associated infiltrate | Stromal thinning

What two things may occur with aggressive forms of moorens ulcers? Is it common or rare?

Aggressive forms may result in corneal scarring and perforation Is rare

How does moorens ulcer appear and where does it typically begin? What shape does it have? How long

Peripheral corneal ulceration with epithelial defect beginning nasal or temporal but crescent shaped and a number of clock hours long

List four differential diagnoses for moorens ulcer.

Other peripheral ulcerative changes Microbial keratitis HSV limbitis HZO

What is the mainstay treatment for moorens ulcer? Is a referral needed?

Refer to establish diagnosis Systemic steroids and other immunosuppressants mainstay Topical steroids and prophylactic antibiotics also used

Is thygesons superficial punctate keratopathy common or rare? Is it uni- or bilatera?

Rare bilateral

What is the aetiology of thygesons superficial punctate keratopathy?

Unknown, but presumed viral

What is thygesons superficial punctate keratopathy?

Corneal inflammatory condition

When is the onset of thygesons superficial punctate keratopathy greatest?

Greatest in the second decade

What is thygesons superficial keratopathy characterised by (2)? How long does the active phase last for and how is the remission?

Remissions and exacerbations Active phase - 1-2 months Remissions - up to 2 months

Do thygesons superficial punctate keratopathy attacks tend to increase or decrease with age? Do they ever cease?

Tends to decrease | Ceases after many years

Does thygesons superficial punctate keratopathy resolve with or without sequelae? How long may it last?

Often resolves without sequelae after 2 -4 years but may last up to 20 years

List 4 symptoms of thygesons superfiical punctate keratopathy.

Photophobia Tearing FB sensation May have mild decrease in vision

Describe the active phase of thygesons superficial punctate keratopathy. What kind of staining would be seen? Is there any haze on the epithelium or is it clear? Does it leave scars behind? What surface appearance does it give the cornea?

``` Raised epithelial lesions Negative or no fluorescein staining Can be faint epithelial haze Never scars Gives corneal surface appearance of having coarse breadcrmbs on the surface ```

What degree of conjunctival injection is present in the active phase of thygesons superficial punctate keratopathy?

Mild conjunctival injection

What number of lesions may be present during the active phase of thygesons superficial punctate keratopathy?

1 - 20 is the most common, can be more

What occurs during the inactive phase of thygesons superficial punctate keratopathy?

Lesions may disappear or leave flat epithelial grey area

List the three components to assessing thygesons superficial punctate keratopathy.

History Slit lamp Fluorescein

What is the mainstay treatment for thygesons superficial punctate keratopathy? When is the ideal time for this? What must be done if this treatment option is given? List 2 additional treatment options.

Mainstay is moderate strength topical steroid during exacerbation - greatly reduces course (careful tapering needed) Bangage contact lens can reduce symptoms Ocular lubricants for discomfort IOP must be monitored if steroids are given

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AED - Superficial Corneal Diseases - Week 9 Flashcards

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